Proof Of DC Residency Application (Au Pair)

GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF MOTOR VEHICLES PROOF OF DC RESIDENCY CERTIFICATION FOR AU PAIR APPLICANT INFORMATION Last Name (including suffix) First Name Middle Name Date of Birth Address Telephone Number with Area Code E-mail Address Apt/Unit Number City/State Zip Code WASHINGTON, DC Au Pair Agency CERTIFIER INFORMATION (HOST FAMILY) Last Name (including suffix) Address First Name Apt/Unit Number Middle Name City/State Date of Birth Zip Code WASHINGTON, DC Telephone Number with Area Code E-mail Address DC Driver License or DC Identification Card Number Expiration Date The certifier must sign this form attesting that the above applicant resides with them in the District of Columbia. The certifier must also provide a valid DC Driver License or valid DC Identification Card reflecting their name and the address listed above AND two (2) of the following proof of residency documents reflecting their name and DC address. Utility Bill (water, gas, electric, oil or cable) issued within the last 60 days Telephone Bill (cell phone, wireless, or pager bills accepted) issued within the last 60 days Unexpired Lease or Rental Agreement with the name of the certifier as a lessor, lessee, permitted resident or renter DC Property Tax Bill issued within the last 12 months Home Security System Bill issued within the last 60 days Unexpired Homeowner's or Renter's Insurance Policy Official Mail ­ received within 60 days from ANY Government Agency to include contents and envelope Unexpired Sublease accompanied by the original unexpired Lease with the name of the certifier as sub-lessor Bank Statement issued within the last 60 days Credit Card Statement issued within the last 60 days Student Loan Statement issued within the last 60 days Car/Personal Loan Statement (coupon books or vouchers are NOT accepted) issued within the last 60 days Home Line of Equity statement issued within the last 60 days Deed or Settlement Agreement Investment Account Statement issued within the last 60 days Medical Bills issued within the last 60 days Any person using a fictitious name or address and knowingly making any false statement on this application is in violation of DC Law and subject to a fine of not more than $1,000 or 180 days imprisonment or both. (D.C. Official Code §22-2405) I hereby certify that the information contained on this application is true and correct. Applicant's Signature: Certifier's Signature: Date: _______________ _______________ Date: _______________ FOR DMV OFFICIAL USE ONLY DMV EXAMINER SIGNATURE:___________________________________________DATE:____________ If you have questions, please visit our website, www.dmv.dc.gov, or call 311 in DC or 202-737-4404 outside the 202 area code. To confidentially report waste, fraud or abuse by any DC Government Agency or official, call the DC Inspector General at 1-800-521-1639. DC DMV-PRA-002 Version 8/2015 American LegalNet, Inc. www.FormsWorkFlow.com